Review of Hospital Drinking Water Supply Options For KGH

Review of Hospital Drinking water supply options.
Version 1 August 21, 2015
Review of Hospital Drinking Water Supply Options

and Recommendations for Koidus Hospital
Author: Trish Morrow, Senior WaSH Engineer

Date Last Updated: August 21, 2015
Document location: Dropbox/ Koidu Government Hospital/Water Sanitation Hygiene Dropbox//Review of Hospital
Drinking Water Supply Options for KGH.docx
Executive Summary
To prevent nosocomial infections and enable an adequate response to illness, focusing on
infection prevention and control, a reliable source of drinking water is needed for Koidu
Government Hospital. Risks of illness from unsafe water are considered in this document, and it
is concluded that these risks are sufficient to warrant an economic investment in hospital drinking
water, even when the source shows little contamination. This document reviews the standards
for water supplies in health facilities, investigates the practices carried out in other hospitals, and
discusses some options for drinking water management for Koidu. The recommended method of
water treatment is chlorination followed by point-of-use filtration. In the long-term, ALL of the
hospitals water will need to be filtered to provide safe potable water from every tap. As it will
take some time for staff and patients to adjust to chlorinated and filtered water, however, in the
short term it is proposed that a 1 micron point-of use filter be installed for a 1500L Milla tank on
a tankstand to be built near the incinerator and the male ward, and that chlorination using
Dosatron in-line chlorinators be progressively introduced for all of the hospitals Milla storage
tanks.
1
Review of Hospital Drinking water supply options. Version 1 August 21, 2015
1. RISKS ASSOCIATED WITH UNSAFE DRINKING WATER IN HOSPITALS

The risk of nosocomial infections in a hospital can be greatly reduced by access to good quality
drinking water for patients. In African countries such as Kenya, diarrhoeal infections among
pregnant women and children, due to contaminated drinking water in hospitals, are common1
In the poorest and middle-income countries, an estimated 58% of diarrhoea cases are caused by
inadequate drinking water, poor sanitation and insufficient hand hygiene. 2 Every year,
approximately 502,000 people who drink inadequate drinking water die from easily-preventable
diarrhoea 2. The overall mortality from water-related diseases is more than 5 million per year,
with more than 50% due to cholera and other intestinal infections2.
In Sierra Leone, water-related disease kills more than 400 people per 100000 every year.3 At
least 1.8 million children under five years die every year, worldwide, due to water related disease,
or one every 20 seconds (WHO, 2008). Some of these shocking, easily-preventable deaths can be
traced back to diarrhoea acquired from hospitals. Untreated drinking water from hospitals can
greatly increase the risk of death, if patients drink it rather buying their own bottled water or
treating their own water4
People with water-related illnesses fill half the developing worlds hospital beds5, and for those
with weakened immune systems who are in hospital, drinking untreated water is even more of a
risk than for the healthy population outside the facility. In fact using unsafe water, not only for
drinking, but also for hospital procedures such as delivering babies can lead to the sepsis which
causes up to eight per cent of maternal deaths globally, as well as neonatal nosocomial infections
which cause up to 56 percent of the deaths of babies born in third world countries6. Considering
a number of different environmental health interventions to provide health benefits, Olmstead
(2010)7 concludes that the provision of piped drinking water is the most cost-effective.
1
See for example http://www.onewater.org/stories/story/africas_deadly_hospitals
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996186/
3 http://www.unep.org/pdf/SickWater_screen.pdf
4 http://www.onewater.org/stories/story/africas_deadly_hospitals
5
Human
Development
Report
2006;
United
Nations
Development
Program,
2006,
cited
in
https://www.google.com.sl/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CCMQFjABahUKEwiMw4yj57LHAhUBFCwK
Hf6WDyw&url=http%3A%2F%2Fwww.wateraid.org%2F~%2Fmedia%2FPublications%2FWASH-in-health-care-facilities-in-Asia-and-thePacific.pdf&ei=ZjzTVYz4HoGosAH-rb7gAg&usg=AFQjCNF5SSgq4RYvsGf_cEwZL-BHeGCsA&sig2=SOPhpOn2aLfW8q0k0I0JIg&bvm=bv.99804247,d.ZGU
6 Report on the Burden of Endemic Health Care-Associated Infection Worldwide; World Health Organization, 2011 cited in
https://www.google.com.sl/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CCMQFjABahUKEwiMw4yj57LHAhUBFCwK
Hf6WDyw&url=http%3A%2F%2Fwww.wateraid.org%2F~%2Fmedia%2FPublications%2FWASH-in-health-care-facilities-in-Asia-and-thePacific.pdf&ei=ZjzTVYz4HoGosAH-rb7gAg&usg=AFQjCNF5SSgq4RYvsGf_cEwZL-BHeGCsA&sig2=SOPhpOn2aLfW8q0k0I0JIg&bvm=bv.99804247,d.ZGU
7
Olmstead, S.M. 2010. The Economics of Water Quality. Review of Environmental Economics and Policy 4(1): 4462.
http://reep.oxfordjournals.org/content/4/1/44.abstract , cited in http://www.efdinitiative.org/sites/default/files/publications/efd-dp-13-10.pdf
Nosocomial infections caused by drinking contaminated water are not restricted to the worlds
poorest hospitals. In Northern Ireland several neonatal units suffered from outbreaks of
Pseudomonas aeruginosa, associated with colonization of water taps8. Similar outbreaks have
also occurred in health care facilities in England and Wales. Hospitals which have piped municipal
water supplies have been found to contain pathogens such as Legionella9, Pseudomonas
aeroginosa, Acinetobacter, Stenotrophomonas, filamentous fungi and different species of
Mycobacterium 10 11. The existence of these pathogens in drinking water does not always imply
a causal relationship between the contaminated water and disease, however after a woman died
in an Austrian hospital from Legionnaires disease, genetic typing firmly established the hospital
water supply as the reservoir,12 justifying economic investments in the hospital potable water
supply.
A study in Istanbul found coliforms such as Enterohemorrhagic E. coli, Enterotoxigenic E. Coli and
Enteropthogenic E. Coli in the tap water from two teaching hospitals13. Opportunistic pathogens
such as Autochtonous Heterotrophic Plate Count (HPC) bacteria have been found in hospital
water supplies also14. While these are not normally considered pathogens, they may cause
infection in sick patients whose immune patients are vulnerable, especially those with HIV, those
who are recovering from surgery or those who are taking immunosuppressant drugs 15. In a
Chinese hospital, of the patients in the ICU with Pseudomonas aeroginosa, forty-two percent
were found to have the same genotype as that which was found in the drinking water taps,
indicating water as the most likely source of their infection. Community-acquired infections of
Clostridium difficile also now point to water as a source of environmental contamination 16 17 18.
Not only can hospital tap water be contaminated, but even bottled water supplied in hospitals
can be a vector for water-related illness. A recent study carried out right here in Sierra Leone19
revealed that 19% of packeted sachet water contained Escherischia coli.
http://www.hpsc.ie/AboutHPSC/ScientificCommittees/Sub-CommitteesofHPSCSAC/WaterGuidelinesSub-Committee/File,14451,en.pdf
http://www.ncbi.nlm.nih.gov/pubmed/21460472#
10
http://www.ncbi.nlm.nih.gov/pubmed/22055394
12 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278599/
11
13
14
http://www.tandfonline.com/doi/abs/10.1080/08927014.2012.757308?url_ver=Z39.882003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed#preview
15
http://www.who.int/water_sanitation_health/dwq/HPC8.pdf
16 http://www.mayoclinic.org/diseases-conditions/c-difficile/basics/causes/con-20029664
17 http://www.usatoday.com/story/news/2015/02/25/clostridium-difficile-infections-grow/23942147/ C. difficile spreading outside hospitals
18 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962320/
19 http://www.ncbi.nlm.nih.gov/pubmed/26162082
2. BACKGROUND AND EXISTING WATER INFRASTRUCTURE

In the early days of PIH working in Koidu Government Hospital, while the hospital had running
water from a solar submersible pump in a borehole near the mens ward, not all of the taps,
showers and WC-type flush toilets were working. This situation has now been greatly improved
with repairs to taps, drains, showers, sinks and toilets in most of the hospitals wards. It is now
time to turn our attention to the quality of the water, rather than just reliability of supply and
volume of storage.
Water Quality Standards
WHOs standards for Health Care in Low Income Settings requires the hospital to Provide safe
drinking-water from a protected groundwater source (spring, well or borehole), or from a treated
supply, and keep it safe until it is drunk or used. Untreated water from unprotected sources can
be made safer by simple means such as boiling or filtering and disinfection.
The SPHERE standards provide guidance for water supply during humanitarian emergencies (such
as Ebola or Cholera epidemics). Minimum standards for water supply during emergencies
whether in refugee camps, schools, health facilities or communities are defined as follows,
Water is palatable and of sufficient quality to be drunk and used for cooking and personal and
domestic hygiene without causing risk to health.20 To ensure that this water is potable the
guidelines recommend implementing a water safety plan for the source and implementing all
necessary steps to minimize post-delivery contamination. For piped water supplies, chlorination
to provide a residual of 0.5mg/L at the tap is required, however this increases to 1mg/L during
outbreaks of diarrhoeal diseases such as cholera.
Water quality testing should confirm, according to the SPHERE standards that there are zero
faecal coliforms per 100mL at the point of delivery. (The previous test for Koidu Government
Hospital revealed the absence of faecal coliforms, though the accuracy of testing is not certain).
With regards to chemical contamination, the SPHERE standards require that any chemicals in the
water do not lead to adverse short-term health effects. In an emergency context, long-term
adverse effects of any naturally-occurring chemicals in the water, or chemical contamination,
does not have to be considered, although obviously it is best practice to avoid both long-term
and short-term effects. (Due to the presence of mining activity in Koidu district, testing of the
water for naturally-occuring heavy metals is recommended).
20
http://www.spherehandbook.org/en/water-supply-standard-2-water-quality/
While chlorine (or any other residual disinfectant) is recommended, the SPHERE standards also
note that, The most appropriate PoUWT option for any given context depends on existing water
and sanitation conditions, water quality, cultural acceptability and the implementation feasibility
of any of the options. 21 For health centres, SPHERE standards require ALL water to be
chlorinated, not just drinking water. There is no requirement or obligation to use any other
supplementary method of water treatment such as UV, filtration or reverse osmosis.
KGH has 1 functional borehole and 3 hand-dug wells, with 2 submersible pumps currently fitted
which supply a series of storage tanks spread throughout the hospital. Those water tanks in turn
use gravity to distribute non-potable water throughout the facility, at present. For Koidu
Government Hospital there is a current total storage capacity of 38,000 Litres, split as follows:
There are Two Milla Tanks near the Environmental Health Office (2 x 5000L), two at the triage
area/holding facility (2 x 1000L), two next to the main productive borehole (2 x 5000L), two near
the paediatric ward (2 x 2000L), one near the outpatients (3000L) one near the male ward (2000L),
one near the latrines (2000L) and one near the female ward (2000L), as well as one in the grounds
of the morgue (3000L). The total storage capacity is 38,000L.
Near Environmental Health Office: 2 x 5000L Milla tanks

Triage/Holding facility: 2 x 1000L tanks
Next to main productive borehole: 2 x 5000L Milla tanks
Near paediatric ward: 2 x 2000L tank
Near outpatients: 1 x 3000L tank
Near male ward: 1 x 2000L storage tank
Near the old latrines: 1 x 2000L
Near female ward: 1 x 2000L
In the grounds of the mortuary: 3000L
A map of the hospitals existing water supply infrastructure is illustrated overleaf:
21
http://www.spherehandbook.org/en/water-supply-standard-2-water-quality/
Map of Koidu Government Hospital
Note: The location of the proposed short-term drinking water supply is marked in Green.
6
It is proposed to build a small tankstand next to the hand dug well. This would be used for
supporting a 1.5L Milla tank for provision of drinking water in the short term. While the SPHERE
standards require that ALL water supplied from the hospital taps be potable, it will take some
time for staff and patients to adjust to point-of-use filters and chlorinated water, so it is proposed
that at first only this tank stand be used for a water point which will have a 1-micron point-ofuse water filter.
At present, the drinking water used at the Koidu Government Hospital is in small plastic bags,
purchased by PIH at a cost of up to $1500USD/month. This practice is not without health risks
its own22 2324, as well as being expensive and leading to a mountain of plastic waste to be burnt.
3. DRINKING WATER SUPPLY IN OTHER HOSPITALS

A recent worldwide survey of 66,101 health centres and hospitals, drawn from 54 countries,
shows that 38% of these facilities do not have an improved water source at all. When
consideration is given to the distance from the water services to the point of use (which may be
up to 500 metres outside the health facility), as well as the quality of the water and
reliability/timeliness of the supply, coverage drops by half.25 The report of this survey further
considers case studies in certain health facilities to conclude that water treatment for these
22
23
24
25
http://io9.com/how-to-recognize-the-plastics-that-are-hazardous-to-you-461587850
http://apps.who.int/iris/bitstream/10665/154588/1/9789241508476_eng.pdf?ua=1
centres leads to an increased number of patients seeking treatment, improved quality of care
and a role model for patients who are encouraged to practice new hygiene-related behaviours in
their own homes.
In spite of the SPHERE standards and WHO guidelines, few health facilities in Africa and lowincome countries in other continents provide potable water from every tap. More than a third
of health facilities in poorer countries do not have any water supply at all.26 Two-thirds of Kenyas
hospitals are in substandard condition, most without running water at all, let alone potable
water27. Zambia is one notable exception. In Zambia the Ministry of Health decided to improve
access to drinking water in health facilities, by providing drinking water at a centralized location
in each facility rather than at every tap in the hospital or health centre28. Two water stations
were placed at strategic locations in each health centre: one x 60 litre water station provided
chlorinated drinking water and one x 70 litre water station provided handwashing water.
Reductions of infant mortality have been achieved in Brazil due to the provision of piped potable
water 29 In China, point-of-use water filters have been installed in a liver transplant unit not only
for drinking water but also to treat the municipal water supplies which are used for surgery 30.
Just over a quarter of the taps were fitted with these filters. The installation of these filters
reduced nosocomial infections.31 Similar results were found for a Hungarian hospital32 where
Pseudomonas and Legionella were eliminated from drinking water using point-of-use tap filters.
A large hospital in Karachi, Pakistan, had no drinking water provision for patients, however a local
social welfare organization installed two tanks and drinking water coolers33. Cool water is also
sold to hospital patients by the glass by local vendors. It is not known whether this water is
treated.
Hospitals in Czech Republic, the Philippines and Indonesia produce disinfection chemicals from
salt by electrolysis34. The result is a combination of chlorine-dioxide, chlorine, oxygen and ozone35
which destroy many pathogens in the water.
26
http://www.who.int/features/2015/zambia-sanitation/en/
27
http://www.onewater.org/stories/story/africas_deadly_hospitals
28
http://www.who.int/features/2015/zambia-sanitation/en/
29Gamper-Rabindran,
S., S. Khan, and C. Timmins. 2010. The Impact of Piped Water Provision on Infant Mortality in Brazil: A Quantile Panel
Data Approach. Journal of Development Economics 92: 188200. Cited in http://www.efdinitiative.org/sites/default/files/publications/efd-dp13-10.pdf
31
http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)60276-7/pdf
33 https://washmediasa.wordpress.com/2010/10/19/patients-attendants-face-drinking-water-shortage-at-chk/
34 http://www.redowater.com/more-hospitals-in-eastern-europe-and-asia-using-redo-technology/
35 http://www.redowater.com/redo-technology/
Colleagues working in hospitals in various low-income countries were consulted to find out how
their water is treated and their responses include the following:
Most hospitals in Africa do not provide drinking water. They may use municipal water
without further treatment or bore water if there is a borehole on site. There are few taps
in most African hospitals
Safe borehole water sources are used, so that there is no treatment apart from shock
chlorination at the time of commissioning the borehole. All taps provide the same water
quality
Municipal water supplies are used if available. Otherwise boreholes are used and then
filtration
Ceramic candle filters are used as a point-of-use water treatment method
Water trucking is used to fill the hospitals water tanks, then there is filtration, with a filter
built-in to the storage tank
Partners in Healths hospitals in Haiti manufacture their own chlorine from salt. This is then used
for disinfection of the Mirebalais hospitals water supply which comes from a 6 borehole and an
8 borehole. All water from every tap and even the water used in the toilets is potable. For our
hospital in Malawi all of the water is chlorinated and the patients drink it.
4. Effectiveness, Advantages and Disadvantages of Different

Methods of Water Treatment
Different options for hospital water treatment include the use of ultraviolet light, point of use
filtration, copper-silver ionization, monochloramines, reverse osmosis, steam distillation,
chlorine dioxide and hyperchlorination 36
CHLORINATION
Chlorination is highly effective against adenovirus, a frequent cause of nosocomial infections.37
If hospital water is stored in tanks for long periods without use it may stagnate and bacteria may
grow in it, and chlorination helps to overcome this problem. 38
36
http://www.ncbi.nlm.nih.gov/pubmed/21460472#
37
38
http://www.waterbank.com/Newsletters/nws46.html
The World Health Organisation recommends the use of chlorine for health care facilities, because
of its effectiveness for eliminating pathogens such as viruses and bacteria39 however it is
ineffective against certain protozoa such as cryptosporidium, amoebas and giardia.40 Chlorine for
drinking water treatment may be used in the form of liquid bleach, bleaching powder (HTH),
tablets or granules. Following chlorination, the minimum contact time required is 30 minutes.
The level of chlorination required depends on the turbidity of the water and its organic matter
content, as well as the level of pathogens in the water.
Following chlorination, under normal conditions the residual chlorine content of the water
should be between 0.5 and 1 mg/L. In times of outbreaks of cholera or other diarrhoeal diseases,
the residual water level can be slightly higher. If water has a turbidity of more than 5 NTU, it must
be either filtered or subjected to sedimentation (with or without a flocculant) before
chlorination.
During the Ebola epidemic, inactivation of the Ebola virus in drinking water is a prime concern.
Chlorine is a highly effective disinfectant against Ebolavirus, in fact in general enveloped viruses
such as Ebola are even more sensitive to chlorine than non-enveloped viruses. Chlorination with
a contact time of 30 minutes and a residual of 0.5mg/L will achieve a 99.99% reduction in the
virus population of drinking water (a 4-log10 virus reduction), including polioviruses, rotaviruses
and adenoviruses.
Chlorine is an effective disinfectant against most bacteria and viruses, however some bacteria
are quite resistant. The resistance of non-tuberculosis mycobacteria to chlorine is unfortunately
100-330 times more than that of E. coli.41 Unfortunately these bacteria are also resistant to
filtration42 even if a 0.2 micron fine filter is used. Though filtration certainly reduces their
population43 it does not eliminate them.
Of all the different methods of water treatment, chlorine is one of the few which provide a
residual disinfection effect throughout the pipeline, in the cisterns of toilets, and in shower
water. Its use is also recommended by WHO for health facilities in low-income countries, unlike
other disinfection methods.
39
40
http://www.who.int/water_sanitation_health/hygiene/settings/ehs_health_care.pdf.pdf
http://www.cdc.gov/healthywater/pdf/drinking/Backcountry_Water_Treatment.pdf
41
43 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2074995/pdf/0325-07.pdf
42
10
FILTRATION
Point-of use filtration has been used to good effect in a Chinese hospital, where it has led to
reductions in levels of pathogens such as Legionella, filamentous fungi, Pseudomonas and
Mycobacterium.44 Examination of patients specimens also indicated a 47% decrease in
colonisations involving Gram-negative bacteria. Filtration with a filter of 1 micron or less is also
highly effective at removing parasites (protozoa) from the water45, which makes filtration an
effective complement to chlorination.
In a Hungarian hospital, the use of disposable point-of-use water filters completely eliminated
Pseudomonas infections, which previously had been running at 2.71 cases/100 patient days
before the introduction of the filters46.
Unfortunately non-tuberculosis bacteria are resistant to filtration47 as well as chlorination even
if a 0.2 micron fine filter is used. However, filtration does indeed reduce their population
significantly48.
Point-of-use filtration is a practical option for Sierra Leone, as 1 micron filters and replacement
cartridges, such as the SunSafe model illustrated below, can be purchased in Freetown.
44
http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)60276-7/pdf
http://www.cdc.gov/healthywater/drinking/travel/backcountry_water_treatment.html
46 http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)60276-7/pdf
48 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2074995/pdf/0325-07.pdf
45
11
This model has been tested in offices in both Port Loko and Koidu and has been found to give an
acceptable flowrate and improve the perception of water quality, leading to likely acceptance by
the users.
COPPER-SILVER IONISATION
The use of copper-silver ionisation systems in hospitals has been found to reduce the populations
of moulds and yeasts, and effectively control Legionella49 50 51. Copper-silver ionisation is used
in approximately 120 British hospitals in England for Legionella control. It has also successfully
reduced fungal populations. 52 Small copper silver ionization systems can be purchased for less
than one thousand dollars53 54, however hospital staff in Sierra Leone are not familiar with this
technology so it would likely be difficult to introduce. While copper-silver ionisation has a residual
disinfection effect, there are concerns about pathogens becoming resistant to it. The operation
and maintenance requirements are likely to be more onerous than that for chlorination, with
which many staff have now become familiar as a result of the Ebola epidemic.
ULTRAVIOLET DISINFECTION
Ultraviolet radiation is highly effective against viruses, including Ebola55, however it has no
residual disinfection effect. The use UV disinfection systems can be purchased for a few hundred
dollars56. These devices, however, are not readily available in Sierra Leone and need to be
imported. This makes them less of a sustainable option than simple filtration systems.
CHLORINE DIOXIDE
Chlorine dioxide is another disinfection method which is effective against Ebola57, in fact is far
more effective than chlorine bleach as it has higher degree of microbiocidal activity and it can
attack biofilms (such as those which could form inside drinking-water taps)58. Unfortunately, it
49
Lin YE, Stout JE, Yu VL. Controlling Legionella in hospital drinking water: an evidence-based review of disinfection methods. Infect Control
Hosp Epidemiol. 2011;32:166-173.[PubMed] [DOI] cited in http://www.wjgnet.com/2220-3176/full/v2/i4/77.htm
50
Stout JE, Yu VL. Experiences of the first 16 hospitals using copper-silver ionization for Legionella control: implications for the evaluation of
other disinfection modalities. Infect Control Hosp Epidemiol. 2003;24:563-568.[PubMed] [DOI], cited in http://www.wjgnet.com/22203176/full/v2/i4/77.htm
51 http://www.lenntech.com/processes/disinfection/chemical/disinfectants-copper-silver-ionization.htm
53 http://www.ebay.com/itm/New-Enriched-Products-Tarn-Pure-TEP00275151-Copper-Silver-Ionization-System/121433255983?hash=item1c45fc702fhttp://www.ebay.com/itm/New-Enriched-Products-Tarn-Pure-TEP00275151-Copper-Silver-IonizationSystem-/121433255983?hash=item1c45fc702f
54 http://www.ebay.com/itm/Copper-Silver-Ion-Pool-Purifier-Mineral-Sanitizer-M425-/230399057082?hash=item35a4da9cba
55
http://www.cdc.gov/vhf/ebola/prevention/faq-untreated-sewage.html
56
http://www.ebay.com/bhp/whole-house-uv-water-filter
57
http://www.cdc.gov/vhf/ebola/prevention/faq-untreated-sewage.html
58
12
produces chlorite as a disinfection byproduct and this is toxic to newborn babies, depending on
its concentration. It may also cause haemolytic anaemia and congenital heart defects59. Because
it is gaseous, chlorine dioxide rapidly reduces its concentration in drinking water, making it
difficult to maintain an effective residual. There are also important safety concerns surrounding
the production and use of chlorine dioxide, making it less suitable for use in Sierra Leone.
Cost of chlorine dioxide systems also precludes their use in Sierra Leonian hospitals. A US 438bed hospital60 estimated that it cost them around $34000 USD per year to operate and maintain
a chlorine dioxide system. The costs of monitoring alone (eg. for control of chlorite) were
estimated at around $5000 USD. Chlorine dioxide is thus not considered an ideal option for Port
Loko Government Hospital.
MONOCHLORAMINES
While Monochloramines provide effective disinfection against nosocomial infections such as
Legionella, there are concerns about toxicity of disinfection by-products. The production of
Monochloramines is a highly complex operation which would require a level of education which
is not available among the staff of Koidu Government Hospital. It also gives the water an
unpleasant ammonia-live smell which patients and staff in Sierra Leone would not appreciate.
STEAM DISTILLATION
A steam distillation unit, similar to those shown on the following website, would produce water
which is completely free of contamination: http://www.waterwise.com/productcart/pc/waterdistillers.asp However, this type of system is too complex and sophisticated to be used for
drinking water treatment, as well as removing valuable minerals in the water. It is recommended
that such a unit be purchased and used for occasions when completely sterile water as needed
(eg. For dialysis of kidney patients) rather than for drinking.
REVERSE OSMOSIS
While small reverse osmosis systems are available on the internet for purchase for less than a
few hundred dollars61, these systems are not readily available in Sierra Leone. The fact that
nearby Port Loko Government Hospitals existing reverse osmosis system appears to have being
lying unused since 2009 implies that this type of system is unsustainable for Sierra Leonian
hospitals, due to its operation and maintenance requirements.
59
http://www.legionella.org/linstoutyu2011iche.pdf
http://www.legionella.org/linstoutyu2011iche.pdf
61http://www.ebay.com/sch/i.html?_from=R40&_trksid=p2053587.m570.l1313.TR12.TRC2.A0.H0.Xreverse+osmosis.TRS0&_nkw=reverse+osmos
is&_sacat=0
60
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5. Discussion
Considering all of the available evidence, the best option to supply drinking water for Koidu
Government Hospital at low cost and with a low risk of nosocomial water-related infections is
chlorination followed by a nationally- available 1 micron in-line point of use water filter attached
to the tap where the water will be drawn. To comply with the SPHERE standards ALL of the
hospitals water supply would have to be chlorinated and filtered. In the short term, however, it
is proposed that only the tank on the low level tankstand, to be built near the hand dug well be
filtered, to allow patients and staff to become accustomed to the filter. The proposed location of
the new drinking water filter at the outlet tap is illustrated below:
New tankstand similar to that illustrated to be build near Hand Dug Well.
Filter to be attached to tap at outlet
QUANTITY OF WATER TO BE CHLORINATED AND DAILY CHLORINE REQUIREMENT

KGHs water storage capacity is to be set to 39,500L, with the ability to quickly expand an
additional 10,000L should the need arise (e.g. for emergencies like cholera). Chlorine for drinking
should be added to give a residual of 0.5ppm. It can be added in the form of tablets, powder or
liquid bleach. If a continuous-flow chlorine dosing pump such as a Dosatron62 is used, a 1%
solution is needed. To facilitate the chlorination process and to ensure success, the use of a
Dostatron is recommended. These units do not require the use of electricity, just water pressure,
so that they have minimal running costs as no fuel needs to be purchased. Their maintenance
requirements are very low.
62
http://www.bbcpump.com/markets/industrial/dosatron/
14
If chlorine is added in the form of liquid bleach (approx. 5% free chlorine), then the recommended
dose of chlorine to give a residual of 0.5ppm is at least 10 mL of liquid bleach per 1000L. A jar
test will determine the actual quantity of chlorine needed which will be more like 100mL per
1000L63. To treat 39500L of chlorine, at least 4Litres of liquid bleach will be required daily for
drinking water alone. (more will be needed for use in the isolation unit) and for cleaning.
DESIGN OF TEMPORARY TANKSTAND
A drawing of the tankstand to be used to support a 1500L Milla Tank to supply drinking water is
illustrated below:
63
http://www.themimu.info/sites/themimu.info/files/documents/Guidelines_WASH_ChlorinationNargisResponse_ClusterWG_Jun2008.pdf
15
6. Recommendations
It is recommended that a Dosatron in-line chlorinator be fitted to the outlet line of each of the
four water pumps currently installed/ to be installed in the hospital, just at the point of entry to
the nearest elevated water tank, to chlorinate the entire hospitals water supply. It is further
recommended that, in the short-term, a 1500L Milla tank be installed on a new tankstand, to be
built next to the hand dug well which will be fitted with the new pump. One Sunsafe one-micron
filter should be purchased for the outlet, to supply potable water for filling bottles. Replacement
filter cartridges should also be purchased. In the long term, a filter should be purchased and
installed at the outlet of each of the hospitals 63 taps, to supply potable water for all uses
throughout the hospital.
16

Review of Hospital Drinking Water Supply Options For KGH

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Review of Hospital Drinking water supply options.

Version 1 August 21, 2015

Review of Hospital Drinking Water Supply Options

Author: Trish Morrow, Senior WaSH Engineer

1. RISKS ASSOCIATED WITH UNSAFE DRINKING WATER IN HOSPITALS

See for example http://www.onewater.org/stories/story/africas_deadly_hospitals

http://reep.oxfordjournals.org/content/4/1/44.abstract , cited in http://www.efdinitiative.org/sites/default/files/publications/efd-dp-13-10.pdf

2. BACKGROUND AND EXISTING WATER INFRASTRUCTURE

Near Environmental Health Office: 2 x 5000L Milla tanks

A map of the hospitals existing water supply infrastructure is illustrated overleaf:

Map of Koidu Government Hospital

3. DRINKING WATER SUPPLY IN OTHER HOSPITALS

4. Effectiveness, Advantages and Disadvantages of Different

Filter to be attached to tap at outlet

QUANTITY OF WATER TO BE CHLORINATED AND DAILY CHLORINE REQUIREMENT

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